# NTSB DEN07FA165: Cessna T210M, N732XE, Moriarty, NM, September 24, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 24, 2007, 10:24 local (16:24 UTC) - Place: Moriarty, NM - Coordinates: 34.981666, -105.998336 - Nearby events: https://openairdocs.org/map.md?lat=34.9817&lon=-105.9983&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report June 30, 2008 - Report: Approved by Office Director - Parties: U.S. Customs and Border Protection, Teledyne Continental Motors, Federal Aviation Administration, Cessna Aircraft Company - NTSB case key (mKey): 66743 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN07FA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/66743/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=66743 - Page: https://openairdocs.org/ntsb/DEN07FA165 ## Probable cause the instructor pilot's failure to maintain aircraft control during aborted landing and attempted go-around which resulted in an inadvertent elevator trim stall. Contributing to the accident were the instructor pilot's inadequate supervision during the landing, improper recovery from a bounced landing, and the improper airplane configuration for the attempted go-around. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - supervision - inadequate, pilot in command(cfi) (contributing factor) - recovery from bounced landing - improper, pilot in command(cfi) (contributing factor) - elevator trim - improper, pilot in command(cfi) (contributing factor) - flaps - improper, pilot in command(cfi) (contributing factor) - aircraft control - not maintained, pilot in command(cfi) (cause) - stall - inadvertent, pilot in command(cfi) (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot trainee and instructor pilot were conducting the fifth flight in accordance with a training program developed by the operator. Satellite tracking data showed the airplane conducted four touch and go's, and satellite signal was lost on the fifth landing. A pilot-rated witness, who was located in his airplane at a taxiway/intersection, observed the accident airplane appeared to be set up for a short field landing based on the final approach descent angle and full flap position. Approximately 10 to 12 feet above ground level (agl), the airplane appeared to flare and then drop onto the runway. The airplane bounced and became airborne with the wings in a straight and level position. The airplane then drifted to the right of runway centerline, and the witness heard the "engine power come up." The airplane's nose suddenly pitched up and approximately 30 to 40 feet agl, the airplane stalled and impacted the terrain in a nose low attitude. The instructor pilot stated that he had no recall of the accident flight or the previous several days. Examination of the airframe showed the flaps were in the 30-degree extended position, and the elevator trim was approximately 10 degrees nose up. No anomalies were noted that would have precluded normal operations. The pilot's operating handbook supplement for "Balked Landing" procedures required the retraction of flaps to 20 degrees immediately. An elevator trim stall occurs when full power is applied to an airplane configured with excessive nose-up trim. Positive control of the airplane is not maintained resulting in a stall. These types of stalls usually occur during a go-around procedure from a normal landing. During the previous four flights, the instructor pilot noted on a grade sheet that the trainee was "below standards and needs additional training" on areas to include approach to landing stalls, short-field landings, and judgment. In addition, the instructor pilot noted the following comments, "[Trainee] sometimes struggles with aircraft trim, tries to 'muscle' aircraft...Sometimes initiates flare too high, but has enough finesse for a safe landing -- except for short field landings, where he doesn't have the airspeed to sacrifice. For short field approaches, needs to work on a stabilized approach and not flaring high." The operator's program required an initial assessment to be used as a tool to help develop the individual "Master Training Program" which was to serve as the trainee's "roadmap" to gain experience, skills and knowledge necessary to complete the trainee program. An initial assessment was not completed by the operator for this pilot trainee. ## Factual narrative HISTORY OF FLIGHT On September 24, 2007, at 1024 mountain daylight time, a Cessna T210M single-engine airplane, N732XE, was destroyed when it impacted terrain following a loss of control during landing at Moriarty Airport (0E0), Moriarty, New Mexico. The flight instructor (instructor pilot) sustained serious injuries and the commercial pilot receiving instruction (pilot trainee) sustained fatal injuries. The airplane was registered to and operated by the United States (U.S.) Customs and Border Protection (CBP), Washington, DC. Visual meteorological conditions prevailed, and a company flight plan was filed for the Title 14 Code of Federal Regulations Part 91 instructional flight. The flight departed the Albuquerque International Sunport Airport (ABQ), Albuquerque, New Mexico, at 0934. Prior to departure, at 0929, the instructor pilot and pilot trainee contacted ABQ approach and requested a heading of 060 degrees and an altitude of 9,500 feet mean sea level (msl). At 0933, the airplane was cleared for takeoff from ABQ, and at 0939, radar services were terminated. During the flight, the CBP Air and Marine Operations Center tracked the airplane via satellite tracking. Tracking data showed, at 1004, the airplane approached 0E0 from the north and entered a left downwind for runway 26. The data showed the airplane conducted four landings to runway 26, and at 1024, the satellite signal was lost on the fifth landing. A pilot-rated witness, who was located in his airplane at 0E0 taxiway/intersection D, observed the airplane performing several touch and go maneuvers on runway 26 (The witness was a tow airplane pilot for glider operations based at 0E0). He stated the accident airplane appeared to be set up for a short field landing based on the final approach descent angle and full flap position. Approximately 10 to 12 feet above ground level (agl), the airplane appeared to flare and then drop onto the runway. The airplane bounced and became airborne with the wings in a straight and level position. The airplane then drifted to the right of runway centerline, and the witness heard the "engine power come up." The airplane's nose suddenly pitched up and approximately 30 to 40 feet agl, the airplane stalled and impacted the terrain in a nose low attitude. The witness and another individual exited their aircraft and ran toward the accident site. They observed the right seat occupant (instructor pilot) exit the right side of the airplane and attempt to assist the left seat occupant (pilot trainee) from the left side of the airplane. The witness stated that after impact, a fire started near the firewall and shortly thereafter, the entire airplane was engulfed in flames. At the time of the accident, the winds were from the southwest approximately 15 knots. PERSONNEL INFORMATION Instructor Pilot The instructor pilot, age 37, held an airline transport pilot certificate, issued October 26, 2001, with an airplane multiengine land rating, and a commercial pilot certificate with an airplane single-engine land and helicopter ratings. The pilot also held a certified flight instructor's certificate, issued October 19, 2006, with an airplane single-engine land rating. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on April 24, 2007, with no limitations or restrictions. According to the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1), which was completed by CBP, the instructor's total flight time at the time of the accident was 3,687 hours, with 1,047 in single-engine airplanes, and 711 as a flight instructor. He had accumulated 252 hours in the accident airplane make and model, of which 21 were logged as a flight instructor. In the 90 days preceding the accident, the instructor had accumulated 69 total flight hours, of which 25 were in the accident airplane make and model, and 12 total hours in the 30 days preceding the accident. CBP reported that in 1994, the instructor received his initial flight training at the US Naval Aviation Training Facility, Corpus Christi, Texas. In February 2001, he was assigned as a primary flight instructor in T-34C airplanes. In September 2003, he was hired by the U.S. Immigration and Customs Enforcement service as a pilot. On August 2, 2004, the instructor completed the Cessna 210 initial training per the Aircrew Standardization Manual (ACSM) at the Albuquerque Air Branch. On February 15, 2005, the instructor completed the Cessna 210 initial vendor training with Flight Safety International, Wichita, Kansas. On February 16, 2007, he completed his CBP instructor pilot initial training per the ACSM at the National Aviation Training Center (NATC) in Oklahoma City, Oklahoma. He was designated as a Cessna C-210 instructor pilot in accordance with the Aviation Operations Handbook and the Crewmember Standardization Manual (CSM) on March 8, 2007. On August 3, 2007, the instructor completed a flight review, instrument proficiency check, and Cessna 210 recurrent training at Flight Safety International. On August 23, 2007, he was designated as an instructor pilot in Cessna 100 and 200 series airplanes. On July 10 and 11, 2007, the instructor pilot completed vendor supplied stall and unusual attitude flight training in an Extra 300L airplane. Pilot Trainee The pilot trainee, age 39, held a commercial pilot certificate, issued on December 10, 2000, with airplane single-engine land and instrument airplane ratings. His most recent FAA first-class medical certificate was issued on October 4, 2006, with no limitations or restrictions. According to the NTSB Form 6120.1, the trainee's total flight time at the time of the accident was 512 hours, 444 hours as pilot-in-command, and 7 hours in the accident make and model. The pilot's logbook was not located. CBP reported that in 2004, the trainee received an initial training assessment by the U.S. Border Patrol, El Paso Flight Operations, El Paso, Texas. The assessment was in accordance with Border Patrol procedures at that time, and the pilot indicated he had accumulated 335.7 total flight hours. At an unknown date, the trainee applied for the CBP Pilot Trainee Program. On the application form, the trainee indicated he had accumulated 436 total flight hours. On February 17, 2007, the pilot trainee entered the CBP Pilot Trainee Program. At that time, the CBP's El Paso Air Branch was establishing the trainee program. While the trainee was stationed in El Paso, he logged approximately 72 hours in helicopters while flying with a CBP pilot who held a flight instructor certificate. CBP reported that the trainee's flight time was accrued while serving as a crewmember on operational missions as time permitted. On September 18, 2007, the trainee was sent to the CBP Albuquerque Air Unit to begin his fixed wing flight time in Cessna 210 airplanes. Prior to his arrival in Albuquerque, the trainee received ground instruction and computer based training in El Paso, in accordance to the Aircrew Standardization Manual (ASM). During the five days following the trainee's arrival to Albuquerque, the trainee was scheduled with and trained by the instructor pilot on four of those days. During that time, the trainee accumulated 5.9 hours in the Cessna 210. The training was conducted in accordance with the Pilot Trainee Program issued by CBP Air and Marine on March 20, 2007. The training was also conducted in accordance with training procedures developed by the El Paso Air Branch to supplement the Pilot Trainee Program. During the four days of flight training, the trainee was graded on various components of pre-flight, flight maneuvers, flight techniques, and judgment. A 1, 2, or 3, on a Cessna 100 and 200 series grade sheet, designated the grading format. The grade scores were noted as the following: 1 = Unsafe or well below standards for stage of training and needs additional tra ## Aircraft - Registration: [N732XE](https://openairdocs.org/deregistered/N732XE-2012-10-03), registration cancelled 2012-10-03, S/N 21061850, built 1977 (OpenAirDocs) - Reported make and model: Cessna T210M - Registry model: [Cessna T210M](https://openairdocs.org/model/cessna-t210m) (registry code 2073451) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21061850 - Airframe hours: 5104 - Engines: Teledyne Continental TSIO-520-R9B 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Registered owner: U.S. Customs and Border Protection - Airworthiness certificate: Standard, Normal - Last inspection: Condition, August 1, 2007 - Departed: ABQ, Albuquerque, NM - Destination: 0E0, Moriarty, NM - Flight plan: Company VFR - Airport: 0E0, Moriarty, runway 26, 7,700 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: serious; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review August 1, 2007; seat: right; flight hours: 3,687 total, 252 in this make and model, 2,534 as pilot in command, 69 in the last 90 days, 20 in the last 30 days, 3 in the last 24 hours - Pilot; age 39; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; toxicology performed; flight hours: 512 total, 7 in this make and model, 444 as pilot in command, 22 in the last 90 days, 17 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 242° at 14 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 41 °F - Altimeter: 30.17 inHg - Observed at: 0E0 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20070924826439A](https://openairdocs.org/incident/20070924826439A), Sep 24, 2007: Cessna T210M, Moriarty, NM, Destroyed, 1 fatal. (-23) On September 24, 2007, N732XE, a Cessna model T210M, collided with the ground during touch-and-go manuevers. At approximately 1015 local time, N732XE… ## Docket (32 files) The files NTSB released with the investigation on June 4, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=66743. 18.4 MB in all. - Witness Statements (item 1, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294101&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Satellite Tracking (item 2, .PDF, 451 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294102&FileExtension=.PDF&FileName=Satellite%20Tracking-Master.PDF - Satellite Tracking (2) (item 3, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294103&FileExtension=.PDF&FileName=Satellite%20Tracking%20(2)-Master.PDF - Wreckage Diagram (Cessna) (item 4, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294104&FileExtension=.PDF&FileName=Wreckage%20Diagram%20(Cessna)-Master.PDF - Weather Information (item 5, .PDF, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294105&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - TCM Engine Report (item 6, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294106&FileExtension=.PDF&FileName=TCM%20Engine%20Report-Redacted.PDF - Training Syllabus (item 7, .PDF, 273 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294107&FileExtension=.PDF&FileName=Training%20Syllabus-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 8, .PDF, 621 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295348&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Trainee Information (item 9, .PDF, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40387873&FileExtension=.PDF&FileName=Pilot%20Trainee%20Information-Redacted.PDF - Pilot Trainee Grade Sheet (item 10, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294109&FileExtension=.PDF&FileName=Pilot%20Trainee%20Grade%20Sheet-Master.PDF - Master Training Plan (item 11, .PDF, 414 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294110&FileExtension=.PDF&FileName=Master%20Training%20Plan-Master.PDF - Mission Record (item 12, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40387872&FileExtension=.PDF&FileName=Mission%20Record-Redacted.PDF - FAA Airplane Flying Handbook (item 13, .PDF, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294113&FileExtension=.PDF&FileName=FAA%20Airplane%20Flying%20Handbook-Master.PDF - Elevator Trim Stall Information (EAA) (item 14, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294114&FileExtension=.PDF&FileName=Elevator%20Trim%20Stall%20Information%20(EAA)-Master.PDF - Airframe Records (item 15, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294115&FileExtension=.PDF&FileName=Airframe%20Records-Redacted.PDF - STOL Information (item 16, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294116&FileExtension=.PDF&FileName=STOL%20Information-Master.PDF - Engine Records (item 17, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295349&FileExtension=.PDF&FileName=Engine%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294118&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294119&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 20, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40295351&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1 Ground Scar to Main Wreckage (item 21, .PDF, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294123&FileExtension=.PDF&FileName=Photo%201%20Ground%20Scar%20to%20Main%20Wreckage-Master.PDF - Photo 2 Main Wreckage (item 22, .PDF, 507 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294124&FileExtension=.PDF&FileName=Photo%202%20Main%20Wreckage-Master.PDF - Photo 3 Main Wreckage (item 23, .PDF, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294125&FileExtension=.PDF&FileName=Photo%203%20Main%20Wreckage-Master.PDF - Photo 4 Main Wreckage (item 24, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294126&FileExtension=.PDF&FileName=Photo%204%20Main%20Wreckage-Master.PDF - Photo 5 Main Wreckage (item 25, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294127&FileExtension=.PDF&FileName=Photo%205%20Main%20Wreckage-Master.PDF - Photo 6 Main Wreckage (item 26, .PDF, 464 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294128&FileExtension=.PDF&FileName=Photo%206%20Main%20Wreckage-Master.PDF - Photo 7 Main Wreckage (item 27, .PDF, 499 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294129&FileExtension=.PDF&FileName=Photo%207%20Main%20Wreckage-Master.PDF - Photo 8 Main Wreckage (item 28, .PDF, 485 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294130&FileExtension=.PDF&FileName=Photo%208%20Main%20Wreckage-Master.PDF - Photo 9 Main Wreckage (item 29, .PDF, 504 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294131&FileExtension=.PDF&FileName=Photo%209%20Main%20Wreckage-Master.PDF - Photo 10 Cockpit Cabin (item 30, .PDF, 488 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294132&FileExtension=.PDF&FileName=Photo%2010%20Cockpit%20Cabin-Master.PDF - Photo 11 Engine (Cessna) (item 31, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294133&FileExtension=.PDF&FileName=Photo%2011%20Engine%20(Cessna)-Master.PDF - Photo 12 Propeller Assembly (CBP).JPG (item 32, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294134&FileExtension=.PDF&FileName=Photo%2012%20Propeller%20Assembly%20(CBP).JPG-Master.PDF From the NTSB's public API. 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